The use of emerging technologies in alcohol treatment.

Emerging technologies, such as the Internet and text messaging, have an ever-growing role in providing services to problem drinkers. This article summarizes selected examples of emerging technologies that have been developed and implemented as stand-alone interventions and as part of other face-to-face interventions. It provides a taste of the different opportunities available for implementing emerging technologies as a way to improve the accessibility and effectiveness of services for problem drinkers.

H ow can the greatest number of problem drinkers-an intentionally broad term cover ing the range of drinking behaviorsobtain help given limited health care resources? Emerging technologies such as electronic tools that service providers can use to help problem drinkers may provide a partial answer to this question. This article will outline the rationale for using emerging technologies to help problem drinkers and summarize the types of technologies already being used, along with a review of the research base supporting their use. Some of the tech nologies mentioned in this article, such as the Internet, are fairly new, whereas others, such as telephones, have been in existence for some time, but all have only recently been applied to the treatment of alcohol problems. Several overviews of this topic already have been published (Bewick et al. 2008;Carey et al. 2009;Hester and Miller 2006;Kypri et al. 2005), and, because the state of tech nology is moving so rapidly, the intent of this article is not to provide a system atic review of all the research done in this area. Rather, the summary seeks to provide key examples and commentary on what has been done so far in order to stimulate the reader to consider ways that emerging technologies might be incorporated into one's own practice.
Emerging technologies may have several advantages over traditional methods in promoting quality care for problem drinkers. First, they may increase access to evidencebased treatment to a larger number of people. Currently, most people with alcohol problems never seek facetoface assistance, whether from a specialized treatment agency, from their general practitioner, or even from groups such as Alcoholics Anonymous. Indeed, it is estimated that in Canada and the United States only between 1 in 3 and 1 in 14 people with a drinking problem seek treatment (Burton and Williamson 1995;Cunningham and Breslin 2004;Hasin 1994;Roizen et al. 1978). Common reasons for not seeking treatment include stigma, embarrassment, and a desire to handle problems on their own (Cunningham et al. 1993;Grant 1997;Roizen 1977;Sobell et al. 1992;Tuchfeld 1976). In addition, many people have difficulty accessing treatment, even where there are comprehensive nationwide services, because they live in rural areas, far from any treatment services. Emerging technologies, particularly those delivered over the Internet, have the potential to overcome some of these barriers.
Emerging technologies also may be utilized by segments of the general population traditionally underserved in facetoface treatment. Specifically, a larger proportion of female and older adults access Internetbased interventions (IBIs) than are typically seen in traditional treatment contexts  (Cunningham et al. 2000;Humphreys and Klaw 2001). Taken together, the potential for emerging technologies to supplement standard treatment approaches in a cost efficient fashion, and to promote access to those tradi tionally underserved by our current treatment options, makes this an exciting area for research and development. Recognizing this potential, much research is currently underway.

Definitions
Before moving to a review of emerging technologies and their current research base, it is worthwhile to briefly define some terms. First, the vague term "problem drinkers" was intentionally used to cover the range of drinkers from those who experience a few conse quences and drink beyond recom mended levels to those who could be defined as alcohol dependent. This term is used because many of the studies we review do not clearly define the severity of study participants' drinking problems. It is safe to say that partici pants in research projects which involve interventions without faceto face contact generally have less severe problems than patients clinicians typ ically see in addictions treatment settings (although some will certainly be as severe). An excellent quote by Heather (1989, p. 366) on brief interventions in community settings is as applicable today concerning emerging technolo gies as it was two decades ago about other types of brief interventions: "Thus the evidence shows that brief interventions are effective and should be used for those individuals who are not actively seeking help at specialist agencies. This justification is, again, independent of level of seriousness, although most recipients of community based brief interventions will obviously have problems of a less severe variety. Moreover, when potential clients are not actively seeking help, then the costeffectiveness kind of argument does become relevant and it is ethically legitimate to ask what is the least expensive way of reaching the greatest number of smokers or excessive drinkers, etc." It also is necessary to define what is meant by treatment in relation to emerging technologies. In this article, interventions are roughly classified by length, using the catch phrase "screeners" to describe brief interventions that are approximately 10 minutes long and "cognitive-behavioral treatments" to describe multisession interventions. It should be noted that these distinc tions represent more of a continuum than two distinct categories, because some screeners are quite extensive and some cognitive-behavioral treatments can be quite brief if the participant so chooses. Also, all the interventions discussed in the article can be thought of as different types of treatment if treatment is defined as something that helps problem drinkers reduce the amount they drink. In fact, one of the exciting things about IBIs is that there is quite a lot of evidence such that even brief 10minute screeners can reduce problem drinkers' alcohol consumption. Among the different technologies, some are designed to be used primarily in isolation, without contact with facetoface services, and others are typically used in more traditional facetoface settings.

Emerging Technologies for Use in Isolation
Although some programs can be delivered by a CDROM for use on a personal computer or preinstalled computer software programs (Hester and Delaney 1997; Schinke et al. 2004), the majority of these programs take advantage of the Internet for their delivery. (For a summary of these Internetbased tools, see the textbox.)

Screeners
Online screeners represent the most common IBIs for problem drinkers. They typically ask participants a gen erally short series of questions about their drinking and then provide per sonalized feedback summaries that illustrate their risk of experiencing an alcoholrelated problem. For example, www.AlcoholScreening.org (Saitz et al. 2004) is a very popular freeaccess intervention that uses the Alcohol Use Disorders Identification Test (AUDIT). The World Health Organization developed AUDIT as a brief, 10item screener that provides an indication of the severity of a participant's alcohol concerns (Babor et al. 1989). In the United States, the site AlcoholScreening. org links participants to an online list of treatment resources that allows them to find services in their community, matched by ZIP Code, if they are con cerned by the results of their AUDIT test. This illustrates the potential for Internet technologies to integrate or combine both online and offline intervention components.
A number of other online screening tests are available for general population use. For example, www.DrinkersCheckup. com (Hester et al. 2005) provides a Web adaptation of the popular in person Drinker's Checkup (Miller et al. 1988), which research shows works well in a facetoface setting. However, research has not yet evaluated whether this intervention works when it is delivered over the Internet, so caution should be taken in assuming that it will work in settings with no personal contact.
Research has evaluated the Check Your Drinking (CYD) screener, avail able at www.CheckYourDrinking.net (Cunningham et al. 2006). This intervention not only provides feedback on participants' drinking but compares it with drinking by others of the same age, gender, and country of origin (for the United States, Canada, and the United Kingdom to date) (see the figure for an example of this kind of normative feedback). Three random ized controlled trials tested whether this intervention worked in a faceto face setting (Doumas and Hannah 2008;Doumas and Haustveit 2008;Doumas et al. 2009), and another tested how well it worked when par ticipants accessed the intervention via the Internet from their own homes or another location of their choice (Cunningham et al. 2010). The stud ies showed that participants reduced their drinking in both settings.
Although the screeners discussed above are available to the general public, much of the work on IBIs, and on personalized feedback screeners in particular, has been done with collegestudent samples (Bewick et al. 2008;Elliott et al. 2008;Hallett et al. 2009;Saitz et al. 2007;Walters et al. 2005). As such, some screeners, such as www.eChug.com, are designed specifically for college students. Several randomized controlled trials have shown that eChug works well to reduce student drinking (Walters et al. 2007). Although there is a fee to view the eChug intervention on its home Web site, readers can see a working example by searching for Universitybased copies.
Other collegebased IBIs focus on curbing drinking at specific events. For example, Neighbors and colleagues (2009) developed a successful norma tive feedback intervention to reduce harmful alcohol consumption on a student's 21st birthday. The interven tion included personalized feedback, based on information collected a week before the person's birthday, which highlighted how much the person was planning to drink on his or her birthday compared with how much people usually drank on their 21st birthday. This study demon strates the extent to which IBIs can be tailored and personalized to target situations as well as to the particular demographic and drinking character istics of participants.

Cognitive-Behavioral Treatment Programs
Several IBIs contain a wide range of cognitive behavioral tools to help problem drinkers. All of the programs mentioned below contain many of the tools that are commonly used in facetoface settings such as drinking diaries, goal setting exercises and relapseprevention techniques. A Dutch language site, www.minderdrinken.nl, for example, which has been subjected to a randomized controlled trial, showed that people who used it reduced their drinking 6 months later (Riper et al. 2008

Other Emerging Technologies
A variety of other emerging technologies have potential to help problem drinkers outside of the traditional facetoface settings. One is the tele phone, which, although it is more than 100 years old, is relatively new as used in alcohol treatment interven tions. For example, researchers have recently found that telephonebased counseling (Bischof et al. 2008;Mello et al. 2008) can be quite useful. Of course, mobile telephones, which allow text messaging and Internet access, are an altogether more modern phenomenon, but there is surprisingly little research on interventions primarily delivered in the form of phonebased discussions or automated responses. There is, however, some evidence that text messaging can be used to encourage smoking cessation (Rodgers et al. 2005). There also has been success with alcohol and drug counseling done online in real time, rather than face toface, allowing access to people who might not otherwise have access (Swan Online support groups also can be used to help problem drinkers. Many common support groups, including Alcoholics Anonymous and Moderation Management, have an online coun terpart (http://aaintergroup.org and www.moderation.org, respectively). Research on the utilization of online support groups on their own (Cunningham et al. 2008;Humphreys and Klaw 2001) and in conjunction with other IBIs (Hester et al. 2009) has found that, although not everyone will choose to use online groups, they can be a good source of support for those who do take advantage of them.

Examples of InternetBased Interventions
Some IBIs target specific population groups, including women living in rural areas (FinfgeldConnett et al. (2008) and members of the military (Williams et al. 2009). Studies of these targeted interventions show promise, and it is likely that IBIs specialized for particular target groups will be an emerging area over the next several years (e.g., Schinke et al. 2009).

Emerging Technologies for Use in FacetoFace Settings
In large part, the types of emerging technologies for use in facetoface set tings mirror those found for the no con tact interventions summarized above.

Screeners and Cognitive-Behavioral Treatment Programs
Treatment providers are beginning to recognize that computerized, and largely Internetbased, interventions can be useful even in settings where patients see providers face to face. Kypri and colleagues (2008) found that it is useful and efficient to use a computerized screener to provide patients seeking treatment from their primary care providers with feedback about their drinking (also see, Linke et al. 2005;Meyer et al. 2008). Others have used a normative feedback screener to assess the drinking norms of a live group, such as an athletics team, and then provide feedback based on the combined responses of the group (LaBrie et al. 2008(LaBrie et al. , 2009).

Emerging Technologies for Use in Different Settings
Some research has examined using computerized interventions in special ized settings, including the emergency department in hospitals (Maio et al. 2005), prenatal clinics (Armstrong et al. 2009), and schools (Newton et al. 2009), as well as to help provide services to people with concurrent alcohol problems and mental health concerns (KayLambkin et al. 2009). In addi tion, research suggests that emerging technologies streamline and improve work done in addiction treatment set tings (Carroll et al. 2008;Vahabzadeh et al. 2009) and the automated col lection of followup data (Helzer et al. 2008).

Research Methods
The strength of any conclusions that can be made about the efficacy of different interventions will largely depend on the research designs employed to evaluate emerging tech nologies used to treat problem drinking (Cunningham and van Mierlo 2009;Murray et al. 2009). As with many research questions, the best way to study whether an intervention works is by conducting a randomized con trolled trial. Without that type of design, it is difficult to draw conclusions about the cause of any effect seen.
Some study design elements are of particular relevance to studies investi gating emerging technologies. For example, in IBI research attrition bias can be highly problematic. It is not unusual for IBI trials to retain only 35 to 40 percent of participants at followup. This is so common that it has even been labeled "the law of attrition" (Eysenbach 2005). These levels of loss to followup seriously jeopardize the reliability of treatment effect estimates, particularly if different treatment groups have different attri tion rates. There are evidencebased measures, such as providing incentives for participants who respond to research followups, that, though expensive, can improve participant retention rates. As such, researchers should consider using them to increase the value of their studies.
Finally, studies can be more or less informative depending on whether they examine the efficacy of an inter vention-often undertaken in more artificial research conditions-or the effectiveness of an intervention-under taken in more realworld-intended application conditions. In IBI research, for example, if an intervention is designed to be administered over the Internet, a research trial in which the intervention is delivered in a faceto face setting has limited utility. This is because people may comply with an intervention when they are confined within the setting of a facetoface laboratory but may easily get bored and move on to some other Web site when they look at the same interven tion online in the privacy of their own homes (Cunningham and van Mierlo 2009;Danaher et al. 2005). Thus, it is important to consider whether the emerging technology under consideration for adoption was actually evaluated in a setting similar to the one in which it will be used.

Future Directions
In looking at emerging technologies and the treatment of problem drinking, it is clear that there is a wide range of modalities and settings in which these technologies can be applied. This article only has examined a small subset of researchsupported applications that include Internet and computer program-based screeners and full intervention programs as well as telephone, email-, and text messagebased applications. Similarly, it has highlighted interventions that are delivered over the Internet via online social support groups, in primary care settings, in emergency departments, in prenatal care services, and in schools.
The key theme is that most, if not all, emerging technologies that provide new ways for people to communicate with each other can be used to deliver help to problem drinkers. In addition, each of these technologies has the potential to be used in specialized treatment, general health care, or other social service settings to promote accessibility, effectiveness, and cost efficiency of treatment.
Also apparent from this overview is the extent to which these emerging technologies still are in their infancy.
Much work needs to be done in order to demonstrate that these tools work both in theory and in realworld set tings and to explore how they can be used most effectively. It also will be important to develop a way to distin guish, for the benefit of consumers, evidencebased IBIs from untested IBIs and to study ways to engage problem drinkers with effective technology based interventions.
One final challenge will be to explore how to integrate these new treatment modalities into traditional faceto face treatment-identifying where this is worth doing and where it is not. There is longstanding recognition that it is important to develop a continuum of treatment opportuni ties for problem drinkers (Institute of Medicine 1990). Emerging technologies are proving to be one tile in this larger mosaic of treatment services for those with alcohol concerns.